Provider Demographics
NPI:1295099745
Name:LIECHTY, JENNIFER ROSE (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:LIECHTY
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:111 MARBLE MILL RD NW STE 300
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1047
Mailing Address - Country:US
Mailing Address - Phone:707-425-7575
Mailing Address - Fax:770-425-7568
Practice Address - Street 1:111 MARBLE MILL RD NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1047
Practice Address - Country:US
Practice Address - Phone:770-425-7575
Practice Address - Fax:770-425-7568
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2020-01-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GARN186511363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I507653Medicare PIN